Provider reimbursement

Information for medical plans

Our goal in reimbursing providers is to provide affordable care for our members while encouraging quality care through best care practices and rewarding providers for meeting the needs of our members. Several different types of reimbursement arrangements are used with providers – all are designed to achieve that goal.

Some providers are paid on a “fee-for-service” basis, which means that the health plan pays the provider a certain set amount that corresponds to each type of service furnished by the provider.
Some providers are paid on a “discount” basis, which means that when a provider sends us a bill, we have negotiated a reduced rate on behalf of our members. We pay a predetermined percentage of the total bill for services.
Sometimes we have “case rate” arrangements with providers, which means that for a selected set of services the provider receives a set fee or a “case rate” for services needed up to an agreed-upon maximum amount of services for a designated period of time. Alternatively, we may pay a “case rate” to a provider for all of the selected set of services needed during an agreed-upon period of time.
Sometimes we have “withhold” arrangements with providers, which means that a portion of the provider’s payment is set aside until the end of the year. Withholds are sometimes used to pay specialty, referral or hospital providers who furnish services to members. The provider usually receive all or a portion of the withhold based on performance of agreed-upon criteria, which may include patient satisfaction levels, quality of care and/or care management measures.
Withhold arrangements are sometimes used to pay primary care, specialty, referral or hospital providers who furnish services to members. The provider usually receives all or a portion of the withheld amount based on performance of agreed-upon criteria which may include patient satisfaction levels, quality of care and/or care management measures along with the financial performance of HealthPartners. Certain factors are measured to determine if the provider has satisfied the withhold criteria such as patient satisfaction, survey results and compliance with industry standards for preventive services, clinical guidelines and care management.
Some providers – usually hospitals – are paid on the basis of the diagnosis they are treating; in other words, they are paid a set fee to treat certain kinds of conditions. Sometimes we pay hospitals and other institutional providers a set fee, or “per diem,” according to the number of days the patient spent in the facility.
Some providers – usually hospitals – are paid according to Ambulatory Payment Classifications (ACS) for outpatient services. This means that we have negotiated a payment level based on the resources and intensity of the services provided. In other words, hospitals are paid a set fee for certain kinds of services and that set fee is based on the resources utilized to provide that service.
Some providers – usually primary care medical groups – are paid based on how well they manage the total cost of care associated with a patient, as well as how well they manage the patient experience and the quality of care provided.

Occasionally, our reimbursement arrangements with providers include some combination of the methods described above. For example, we may pay a case rate to a provider for a selected set of services needed during an agreed-upon period of time, or for services needed up to an agreed-upon maximum amount of services, and pay that same provider on a fee-for-service basis for services that are not provided within the time period or that exceed the maximum amount of services. In addition, although we may pay a provider, such as a medical clinic, using one type of reimbursement method, that clinic may pay its employed providers using another reimbursement method. Check with your individual provider if you wish to know the basis on which he or she is paid.